JB Structures Full Investigation & Report

Title Page

Reference No.
Incident Title
Client / Site / Project
Investigation conducted on
Prepared by

Report

Incident Details

Executive Summary
Date & Time of Incident
Location of Incident
Incident Severity?
Site / Project Name
Incident Type (select all that apply)
- Hazard
- Near-Miss
- Slip & Fall
- Accident
- Injury
- Service Strike
- Theft
- Fire
- Property Damage
- Fatality
- Illness
- Reportable / Notifiable
- Loss Time
- Other
Please describe type of incident
Name of on-duty supervisor at time of incident?
Was medical attention administered?
What kind of medical attention was administered?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance
- Medical Attention Declined
Please detail medical attention

Incident Summary

Who as involved (company's & Individuals, include role`s on site)
Describe what happened. Please be detailed but state only facts.
Do you wish to include a timeline of events for this incident?

Incident Timeline

Build a timeline of key incident events below
Event Date / Time
Event Description
What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
Describe the weather / environmental conditions at the time of the incident

Evidence and Attachments

Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items

Evidence Log

Please log all relevant evidence below
Evidence Description
Evidence ID number (if applicable)
Type of evidence
Photos of evidence (if applicable)
Please detail any further information regarding this evidence (if applicable)

Vehicle Log

Please log all relevant vehicle details below
Vehicle Make
Vehicle Model
Vehicle Registration
Driver (if applicable)
Photos of equipment (if applicable)
Please detail any further information regarding this vehicle (if applicable)

Damage Log

Please log all relevant damage details below
Damage description
ID number (if applicable)
Photos of damage (if applicable)
Please detail any further information regarding this damage (if applicable)

Other Items Log

Please log all relevant details of other items below
Item description
ID number (if applicable)
Photos of item (if applicable)
Please detail any further information regarding this item (if applicable)

Equipment Log

Please log all relevant equipment details below
Equipment Make
Equipment Model
Equipment ID number (if applicable)
Photos of equipment (if applicable)
Please detail any further information regarding this equipment (if applicable)

People involved

Please document all people involved in this incident

Person

Full Name
NI Number
Contact phone number
What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
Describe this person's relation to the incident
Please describe this person's involvement with the incident, including all relevant information
Attach any relevant photos regarding this person
Do you want to log a statement for this person?

Statement

Statement regarding incident
Person Signature
Date & Time of Statement
Has this person sustained an injury?

Injury Details

Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
Describe type of injury or illness
Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
Please describe injury location
Describe this injury or illness
What was the cause of this injury or illness?

Conclusion

Try and be as open minded about the incident as possible and only conclude on the facts available.
What Happened, When, Where and why? Give details as to How and Why you have reached this conclusion.

Root Cause Analysis / Contributing Factors

What were the contributing factors to this incident occurring? (select all that apply)
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
- Unskilled person
- Not briefed
- Company Procedure / System Failure
- Routine activity without thought
A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.
Has the root cause of this issue been able to be identified?
Why is the root cause for this issue unable to be identified at this time?
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
What is the root cause of this incident? Please consider and include all contributing factors
Has the root cause of this issue been rectified or eliminated?
How was the root cause rectified or eliminated?
Please attach any relevant photos or media
Please provide any relevant further details
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable

Corrective Actions, NCR`s and Recommendations

What are the Corrective Actions, NCR`s or Recommendations?
Are corrective/further actions required with regard to this incident?
Please add any corrective actions to the appropriate questions above before completing this incident investigation
Have all required corrective actions been added as Actions to this report?